Enrollees in Cook County’s government-run Medicaid insurance plan may soon have fewer options for where they can get some complicated surgeries.
There are more than 300,000 people enrolled in CountyCare, the largest Medicaid plan for low-income and disabled people in Cook County.
CountyCare members who want or need certain types of surgeries in four areas — gynecologic oncology, pancreatic/liver, colorectal and vascular — would need to have them done at the county’s flagship John H. Stroger, Jr. Hospital on the Near West Side, or at a hospital in the CountyCare network that meets specific criteria, such as cost and quality.
The move could mean more money flowing to the financially challenged county health system, which runs CountyCare, Stroger, Provident Hospital on the South Side, and a network of clinics. Restricting where CountyCare members can get certain surgeries is likely to begin in early 2020.
CountyCare initially wanted to funnel the majority of these surgeries to Stroger, but later walked that plan back.
Dr. Jay Shannon, who is CEO of Cook County Health, said steering more business to the county health system has been a goal since launching CountyCare in 2013. The health system already restricts where CountyCare members can receive bypass, cancer services and bariatric surgery to lose weight, for example.
“We don’t do this for things that we can’t do,” Shannon recently told WBEZ. “We don’t do bone marrow transplants. We don’t do heart transplants. And there are a variety of other things that we as health system cannot do or cannot necessarily do well, and so we would never make those decisions at the expense of the patient.
“But for the ones where it does make sense for us and we’ve got that capability, it makes perfect sense,” Shannon said. “And as they say, it’s kind of the first chapter in how to run an insurance plan.”
The move also “helps to preserve and protect the community asset that is Cook County Health because it keeps business in-house,” Shannon said.
Translation: It keeps money from leaving the health system. County officials expect to generate about $8 million next year by steering many surgeries in those four areas their way.
Surgery policy could help prop up struggling health system
Any new revenue is crucial for Cook County Health. The system makes up nearly half of the county government’s overall $6.2 billion budget. Yet it’s facing major financial challenges. The system is considered to be the medical safety net for poor and uninsured patients in the region who don’t or can’t pay for their treatment.
To cut costs, the health system eliminated hundreds of vacant jobs heading into 2020 to close a budget gap, and it expects to provide nearly $600 million in medical care next year that it won’t get paid for.
County commissioners and the health system’s own board members often grapple with how to steer more CountyCare enrollees to the county health system for medical care, instead of losing their business to other private hospitals in the CountyCare network. The majority of CountyCare members see doctors and hospitals outside of the county health system.
The CountyCare insurance network is vast. Besides the county’s two public hospitals and clinics, the health plan includes more than 1,400 primary care providers, about 15,000 specialists and roughly 70 other hospitals, according to Cook County Health.
Yet steering business to the health system could irk some hospitals in the CountyCare network, especially smaller ones that rely on elective surgeries. They can be big money-makers for hospitals.
Hospital CEO: Cost, quality could still keep surgeries at private hospitals
Michael Zenn, CEO of the University of Illinois Hospital and Clinics, which is anchored just a few blocks from Stroger, said it’s not unusual for insurance companies to steer procedures to certain hospitals. In fact, U of I has these deals with other insurers to funnel some transplants, bariatric services and orthopedics to its hospital.
“It’s always because of a combination of cost and fortunately usually more so about quality,” Zenn said.
The idea of private insurers like CountyCare overseeing Medicaid enrollees is to keep people healthy to ultimately save the government money by not having to provide so much medical care.
“We would suspect that over time these types of arrangements would tend to happen in an increasing way,” Zenn said.
He added that it’s in U of I’s interest that CountyCare be successful. Doctors who end up routing their patients to Stroger, for example, still want to make sure they don’t fall through the cracks before and after surgery.
U of I, as well as the dozens of other hospitals in the CountyCare network, will have to meet specific criteria to be able to perform the four classes of surgeries CountyCare plans to restrict to certain hospitals. The criteria would likely include access for patients, quality outcomes and reimbursement rates, a county health system spokeswoman said.
Cook County Health estimates hospitals throughout the CountyCare network performed about 210 surgeries in the four areas last year. The majority of surgeries will likely flow to Stroger next year, and the rest would be performed at other hospitals.
CountyCare’s state Medicaid contract says it must provide equal access to government providers. U of I is a state-owned health system. A spokesman for the Illinois Department of Healthcare and Family Services, which oversees private Medicaid insurers, including CountyCare, would not specifically comment on CountyCare’s surgery plans.
But in a statement, the spokesman said: “We are working with CountyCare on these kinds of questions and others to ensure that its contractual obligations are met and Medicaid members receive the care they deserve.”
Kristen Schorsch covers Cook County politics for WBEZ. Follow her @kschorsch.